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ER Goddess

ER Goddess

The Other Side of ED Psych Holds

Simons, Sandra Scott MD

doi: 10.1097/01.EEM.0000795772.73062.87
    mental health, psychiatric hospitals, psych holds

    ‘Doc, your job is crazy,” my psych patient said. He was in a room where we could easily see him from the nurses’ station, which meant he could easily observe us. “I've watched you for the past two nights.”

    No patient should stay in the ED long enough to be able to say that, especially one who is struggling with any form of psychosis. Yet exorbitant ED hold times are the reality for many patients waiting for acceptance to an in-patient psychiatric bed. They're left to sit in our EDs, staring at a TV, watching us, or—if they're lucky—sleeping. They will often go days without proper treatment.

    Like most EPs, I'm frustrated by our inability to get patients into appropriate psych hospitals expeditiously. I've written previously about the obstacles of getting psych patients admitted and the need for more streamlined medical clearance processes. (“Psych Patients Don't Need Labs, ECGs, or CXRs,” EMN. 2019;41[12]:1; And I've judged the obstructionist practices of staff at receiving facilities who cling to checklists and demand every test. After all, it's not in patients' best interest just to sit in my ED instead of going posthaste to an inpatient setting. Or is it?

    My state's government-run mental health hospitals recently sounded an alarm that made me pause and reconsider. A few weeks ago, five of eight state facilities closed their doors to new admissions, citing unprecedented levels of danger for personnel and patients due to a staffing crisis. To what environment are we sending our psych patients? The picture I'm getting from Virginia's Department of Behavioral Health and Developmental Services (DBHDS) is a grim one.

    Last Resort

    The safety net in Virginia for patients in crisis, known as the bed of last resort law, inadvertently led to crowding of the state-run mental health hospitals. It was a well-intentioned and necessary measure passed in 2014 after Virginia Sen. Creigh Deed's son Gus was discharged from the ED while in crisis because no psych bed could be found for him within a state-mandated deadline. Within hours, Gus stabbed his father and then killed himself. The law states that Virginia's psychiatric hospitals are required to admit patients after an eight-hour period if a bed can't be found at another facility.

    Since the bed of last resort law took effect, the number of temporary detention order admissions to state hospitals rose from 3.7 patients a day in 2013 to 18 a day in 2021, a 392 percent increase. (Alison G. Land, DBHDS Commissioner, July 9, 2021; Private hospitals have the option to be selective about which temporary detention order patients they will admit; state hospitals do not. When private facilities decline patients with difficult behavior, these labor-intensive patients go to the already-overwhelmed state facilities.

    Even before COVID, higher patient-to-staff ratios and mandated overtime pushed the staff at mental health hospitals toward their breaking points. COVID hurled these facilities well beyond what was sustainable for staff and safe for patients. Closures due to COVID made it more difficult to discharge patients because communities lost housing and outpatient service options. At the same time, the isolation and strain of the pandemic coupled with cutbacks in outpatient care triggered more mental health crisis admissions, driving the statewide census to 112 percent of capacity. (Richmond Times-Dispatch. April 20,2021;

    Assaults and injuries within facilities, which have always been a known risk of the job for mental health workers, are escalating due to crowding. On top of facing the danger of physical aggression from patients, workers now also face a new threat to their safety—the risk of exposing themselves and their families to the coronavirus. When employers like Target and Walmart offer higher wages than the starting salary for most direct care workers at state facilities, it's easy to understand why staff leave patient care entirely for positions that pose less risk to their personal health. With a starting salary of just $11 an hour, even staff who want to continue patient care can be lured away to private facilities that offer higher pay. (The Daily Progress. May 2, 2021;

    Empathic ED Staff

    The higher the number of workers who leave, the more untenable it is for those remaining, so attrition increases in a vicious cycle. State psychiatric facilities have 5500 positions across the state, and 1547 are vacant. (Alison G. Land, DBHDS Commissioner, July 9, 2021; With hospitals operating at 60-75 percent of full staffing while admissions continue to rise, the state was left with no choice but to halt worsening danger for patients and staff by closing the majority of their facilities to new admissions. (Richmond Times-Dispatch. April 20, 2021;

    Now the number of these patients left stranded in our EDs grows. What can we do? When we're expected to move people through, yet they sit tying up ED beds and local police officers, it's easy to direct our frustration at the receiving psych facilities. Until the state announced the closure of the majority of its psych hospitals a few weeks ago, I had no idea how dire the situation was, and I'm sure that was the case for many of my colleagues. Understanding what the staff on the receiving end deal with and what our patients may have to deal with when they leave us makes it a little more palatable to have these patients board with us in the ED.

    Empathic ED staff, however, are by no means enough to fix this crisis. Boarding these patients in the ED is not a sustainable solution. COVID relief funds have been seemingly poured into every other facet of society, but clearly not enough has been budgeted for outpatient mental health care or inpatient beds in psychiatric hospitals. If we want to have staff to care for this vulnerable population, workers in state mental health hospitals need better compensation than they can earn at retail chains. We desperately need funds to procure more staff and retain those still giving care. We need private facilities to be more willing to accept patients under a temporary detention order that might be more challenging to manage. We also need more funding for outpatient mental health care and community services to help prevent people from needing hospitalization in the first place.

    Until state psych facilities get more funding and resources, state psych hospitals will be unsafe, psych patients will be stuck in our EDs, and more and more EPs will be asking themselves, “I know my patient can't stay here, but do I really want him going to the unsafe environment in our state psych facilities?” I'd like to see my state and our nation as a whole dedicate dollars, not just lip service, to fixing this dilemma.

    Dr. Simonsis a full-time night emergency physician in Richmond, VA, and a mother of two. Follow her on Twitter@ERGoddessMD, and read her past columns at

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